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Open Access Review Article

Crescent Journal of Medical and Biological Sciences

Vol. 1, No. 4, Autumn 2014, 113-117

eISSN: 2148-9696

Pain after Cardiac Surgery: A Review of the Assessment and

Management
Razieh Parizad1, Farahnaz Abdolahzadeh2, Mitra Mousavi-Shabestari1*

Abstract
Objective: Surgery is among the causes of acute pain. One of the major problems of patients after surgical
procedures is postoperative pain. Annually, millions of people throughout the world undergo surgery
and experience different intensities of postoperative pain. Due to physiological changes and given the
stability of the heart and lung, the management and control of pain is rarely considered as a priority in the
care of patients after cardiac surgery. Cardiac surgical patients experience pain due to the surgical incision
and between the ribs nerve injury created during the course of the surgery, and irritation and
inflammation of the pleura by catheters. Control and management of pain in intensive care units (ICU) are
the main tasks in nursing care. The purpose of this review study was the investigation, assessment, and
management of pain in patients after cardiac surgery.
Materials and Methods: In this study, the literature available on Magiran, Google Scholar, ScienceDirect,
and PubMed were collected, and after reviewing, the relevant literature was studied.
Results: Although pain is one of the major stressors in patients undergoing surgery, the measures taken
for the treatment and care of these patients are associated with experiencing pain. In this regard, all the
resources have emphasized the using of guidelines and tools to assess patients' pain. However, in cardiac
surgery patients, sufficient attention is not paid to pain control. Patients reported poorly controlled pain
and experiences of moderate to severe pain after surgery.
Conclusion: Pain is a subjective experience, and in patients who cannot report their pain, it should be
considered important. According to numerous studies, pain control is not performed in ICUs. Thus,
efforts should be made for appropriate control and reduction of pain, use of valid methods to determine
and control pain, and improvement of the quality of the programs.
Keywords: Assessment, Control, Heart Surgery, Pain

Introduction patients after surgery is postoperative pain. In many

Pain is the most common cause of help seeking by
patients from the medical team. Pain is a subjective
personal experience that can only be described by
the person who has experienced it. Moreover, pain is
an important symptom of a disease and it is
associated with most diseases. Perhaps there is no
scarier feeling than pain for the patient undergoing
medical or surgical treatment (1). After surgery, pain
is a common phenomenon. Operations are the causes
of acute pain. One of the major complaints of
patients the pain is not treated adequately (2,3).
Hundreds of millions of people around the world
undergo surgery every year one of which is cardiac
surgery. Pain affects peace, and physical and mental
health of the individual, and increases heart rate,
respiratory rate, blood pressure, and sleep disorders
(4). Despite the many effective pain relievers,
inadequate pain control after surgery is one of the
most important postoperative problems. Pain is
always a common concern of patients with cardiac

Received: 16 May 2014, Revised: 21 Jun 2014, Accepted: 19 Jul 2014, Available online: 15 Sep 2014

1Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

2Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
*Corresponding Author: Mitra Mousavi-Shabestari, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
Tel: +98 914310261, Email: mousavi sha@yahoo.com
Parizad, et al.
surgery. Patients are always concerned that, after
surgery, pain will prevent them from sleeping and
performing different activities. The degree of pain
experienced is often higher than that estimated, and
thus, pain killers are not prescribed enough (5).
Approximately 3/4 of patients who suffer from acute
and chronic pain and receive narcotic pain
medications still suffer from pain after surgery.
Studies showed that 77% of surgical patients in
intensive care units (ICU) experience pain (2,6,7).
Cultural background affects the meaning of pain and
pain treatment. Pain relief is one of the most
complex issues related to pain, although its
treatment seems simple (8).
The aim of this study was to investigate the
experience of pain and its management in cardiac
surgery patients.
Materials and Methods
In this study, the literature available on Magiran,
Google Scholar, Science Direct, and PubMed were
collected and reviewed.
Results
Based on the study by Cupples on 53 million
surgeries in the United States, 30% of patients
experienced mild pain, 30% moderate pain, and 40%
suffered from severe pain after surgery (8). In the
research by Chung and Lui, the most recognized
nursing problem in surgical wards was pain and
almost 85% of surgical patients complained of pain (9).
Statistical studies showed that the greatest concern of
patients who had heart surgery was pain which often
affected their sleep. Stress factors in patients in ICUs
have shown that pain is the second most prevalent
stressor for operated patients (10,11). An important
note in the care of these patients is that all the pain
experienced by the patients is real, even if there is no
apparent cause for the pain. Therefore, pain is based
on the patients belief of its existence. Thus, nurses
are responsible for the assessment, management,
and treatment of pain. Pain management and control
has more benefits than its discontinuation.
Therefore, by reducing pain, its possible
complications in patients after cardiac surgery can
be prevented (12). The surgical incision and between
the ribs nerve injury created during the course of the
surgery, and irritation and inflammation of the
pleura by catheters cause pain after cardiac surgery.
Postoperative pain control is an important task
for nurses. Listening and paying attention to verbal
and nonverbal expressions of pain by the patient is
very important. Due to the specific circumstances of
patients after heart surgery, admission of patients to
the ICU is necessary for 1 to 3 days. During this time,
due to the endotracheal tube suctioning, coughing,
and physiotherapy, the pain increases (13). Most
nurses believe that cardiac surgery is not very
painful. Nevertheless, many studies have shown that
a majority of patients (71%) after heart surgery, due
to the surgical incision site, experience pain of
114 | Crescent J Med & Biol Sci, Vol 1, No. 4, Autumn 2014
moderate to severe intensity (14-16). In the study by
Parvan et al., pain and discomfort in patients after
coronary artery bypass graft (CABG) surgery was
one of the most stressful conditions presented (17).
Parvan et al. stated that nurses' understanding of
patients' perception of pain was a key factor in
strategic decision making regarding the reduction of
pain and discomfort (17).
Incidence of chronic pain after heart surgery
varies between 21-55%. Pain experienced after
cardiac surgery may have visceral, muscular, or
neurotic sources (18). Age, duration of surgery, the
incision affect pain intensity, and risk factors of
chronic pain include depression, psychological
vulnerability before and after surgery, major
surgery, and operation prolonged more than 3 hours
(18). Pain management is more important than pain
control. Reduction of pain can be followed by the
prevention of possible side effects of pain. A patient
with severe pain has trouble breathing, and lung and
cardiovascular risks followed by effects on other
systems can be expected (19).
Despite recent advances in the quality of
education and treatment of pain, patients complain
of moderate to severe postoperative pain. Patients
who have undergone cardiac surgery have reported
pain, due to receiving insufficient doses of analgesic
drug (20). Control and treatment of postoperative
pain is a complex issue. Although pain control is
important after cardiac surgery, studies showed that
pain was not adequately controlled in these patients,
and in only 30-36% of the patients the maximum
dose of the drug was used (21,22). Based on the data
obtained from this study, the dose of pain killer
prescribed by the doctor and administered by nurses
was lower than that actually required by the patient.
The reason for this was the fear of drug dependency
and respiratory depression. Treatment of pain after
cardiac surgery was discussed for 30 years until the
issue was studied by Watt-Watson and Stevens and
their findings suggested that many nurses believed
that heart surgery was not painful (22). As a result of
incorrect assessment of pain by nurses, protocols
and inappropriate drug use by them, patients
inability or unwillingness to communicate, and the
hypothesis that patients should wake early from
anesthesia and their blood pressure be stable, pain
control is postponed to the next step (21,23-26).
Continuous and periodic pain causes anxiety,
fear, depression, sleep deprivation, anger, and lack of
confidence in the treatment team regarding their
ability and motivation to treat pain. Accurate
assessment of pain is determined by intensity,
quality, and duration of pain (which is different for
each patient). Pain assessment helps in the
identification and selection of the best treatment.
Curtiss, in her study on orthopedic pain assessment
standards, had identified that weakness in the
evaluation of pain leads to weak pain management
(27). The findings of Carroll et al. showed that
hospitals that do not have a specific form for the
Parizad, et al.
assessment of pain were significantly different from
hospitals that had the assessment of pain form
regarding the satisfaction in both groups of patients
(11). Researches from the past 25 years showed that
the inability to control pain resulted from incorrect
assessment of pain by nurses and inadequate intake
of certain medications (28).
The study by Puntillo et al. showed that
inadequate pain control was associated with
increased sympathetic response and ineffective
breathing leading to hypoxia, catecholamine release,
and general reaction to stress (29). Nurses can
support patients and create a calm environment to
help ensure patient comfort. Stein-Parbury and
McKinley reviewed 26 articles and reported that
71% of patients complained of severe pain. These
patients suffered from delusions, memory
impairment, and disorientation. The main
complaints of the patients were inability to sleep,
inability to distinguish day from night, lack of
comfort, and inability to talk. In this paper, the
researchers recommended that nursing
interventions such as frequently informing patients
about their place and time, and helping to reduce the
patient's excitement and assuring them by
explaining to them (30). The study by Desbiens et al.,
on pain and satisfaction with pain control in 5176
patients admitted to intensive care units, showed
that 49.9% of patients suffered from pain, 14.9%
reported high intensity pain, and 14.9% were not
satisfied with pain control. The results of this study
indicated that factors such as race, age, income,
health insurance, and education had no significant
effect on pain intensity (31).
Physical activity also has an effect on pain. The
study by Yorke et al. on control and management of
pain after cardiac surgery in Australia showed that
patients who had undergone intra muscular artery
(IMA) transplant received morphine significantly more
than patients who did not have this transplant.
Moreover, 92% of patients felt pain in the chest wound
area. Regarding physical activity, cough with 95%
followed by physiotherapy (89.2%) and movement
(88.2%) had the greatest effects on pain (15).
Pain assessed by nurses was also effective in
controlling pain. Puntillo et al. determined the
accuracy of nurses in pain evaluation using a
numeric pain scale ranging from 0 to 10 (29). They
showed that nurses measured lower pain intensity
with this scale than the patients, and the patients
pain was at a moderate level. Nonetheless, the
selected dose of morphine for patients was more in
coordination with the pain assessed by the nurses.
The findings showed that the indirect assessment of
behavioral and physiological indicators of pain by
nurses was not accurate (29,32).
During treatment and pain relief after surgery, a
chain of communication exists between the patients'
experience, drug application, prescribing of
painkillers by physician, and decision making and
administration of painkillers by nurses. The main
Crescent J Med & Biol Sci, Vol 1, No. 4, Autumn 2014 | 115
loop of this chain is the patient. Patient satisfaction is
the main goal of the therapy team.
Discussion
Researchers have come to the conclusion that the best
indicator of patient pain is the assessment of the
patient. However, patients in the ICUs are generally
semiconscious or because they are connected to a
ventilator they are unable to communicate and
express their pain. Numeric pain intensity scales that
show numbers to express the pain (lower to higher)
or images that express the pain can be used in order
to solve this problem. Paying attention to
physiological indicators (increased pulse rate,
breathing, sweating, and pale color) and behaviors
such as crying, frowning, moaning, and stretching is
recommended in patients who are semi-conscious
(29,32).
Training before the operation and use of
analgesics for pain control before the onset of pain
after cutting the chest in heart surgery can reduce
pain and the amount of painkillers prescribed after
surgery. The results of numerous studies showed that
the use of preoperative education in the intervention
group in the first 48 hours after surgery decreased the
amount of prescribed painkillers (33-35). It should be
noted that visible behavioral and physiological
indicators of pain may be minimal or not even exist.
However, this does not mean that the patient feels no
pain (32). The results of the studies by Puntillo et al.
(29) and Brouner and Smith (32) showed that nurses
indirect assessment of pain using behavioral and
physiological indicators was not accurate.
Lack of patient satisfaction of pain control in ICUs
can be attributed to the following reasons: patient's
inability to communicate and express pain (due to the
low level of consciousness, intubation); nurses fear of
creating dependency on narcotics; and the patient's
respiratory depression (21,34). Other factors were
also involved in this field including severity of pain,
patients' expectations of pain, and the amount of time
patients waited for receiving painkillers. When a
patient has to wait a long time to receive painkillers or
when the pain is more than expected, pain intensity
will be increased (26).
The art of nursing in pain management includes
simple interventions to create more pain relief for the
patient. Interventions, such as changing condition,
emotional support for the patient and their family,
repeatedly informing the patients about the situation,
explaining the clinical practices for the patient, back
massage, oral care, providing patients with their
favorite entertainment (radio, TV, newspapers, and
etc.), providing visiting time opportunities for the
patient and their family, are worth mentioning.
Patients in the ICU, in addition to disclosing their
negative experiences, also reported their positive
experiences of feeling secure and confident due to the
nurses presence (30). The nurses should assess
patients and provide training based on the individual
needs of the patients (36). Higher knowledge of
Parizad, et al.
nurses and doctors regarding the pharmacology of
analgesics and tranquilizers may also be
recommended. Nurses' and doctors' knowledge about
tranquilizers will help them in clinical decision
making and controlling pain.
Conclusion
Given the importance of pain management and
control, and treatment of postoperative pain, further
studies are necessary in this regard. Patient comfort
is a priority in crises; however, this fact is generally
overlooked. Based on studies of pain in patients after
cardiac surgery, their pain was not appropriately
controlled and they experienced intense pain.
Inadequate pain control can result in negative
patient outcomes. Uncontrolled pain may result in
aggravated sympathetic responses, and thus, affect
the cardiovascular system. These situations can be
improved with the following rules:
1. Increasing the knowledge of physicians and
nurses in the field of pharmacology of analgesics
2. Identifying and eliminating the stress factors
that underlie anxiety and agitation in patients
3. Assigning time to nursing interventions for
patient comfort
4. Providing preoperative patient education
Nurses have a great responsibility for the
assessment and necessary measurement of pain. It is
clear that all patients have moderate or severe pain
after heart surgery and insufficient doses of
painkillers are used. Furthermore, uncontrolled
acute pain can have immediate or long-term negative
consequences for the patient's recovery. Clinical
training should include a clear knowledge of patients
and nurses in the field of assessment and
management of pain. Nursing education programs
should emphasize the primary importance of pain
relief. Detailed reports include reports on patients'
clinical history, continuing studies, protocols for
practices, and interventions for the management of
pain. The patient education program includes
training on how to access the system to request help.
Most patients are not aware of their pain intensity
and are not able to report their pain. Patients should
be taught how and when to express the intensity,
quality, duration, and location of their pain.
Ethical issues
Written informed consents were obtained from the
patients for publication of this study. The study has
been approved by the local ethics committee.
Conflict of interests
We declare that we have no conflict of interests.
Acknowledgments
We would like to express our gratitude to the IT units
of the Shahid Madani Hospital for their assistance in
data collection.
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